patient surgical report with anatomical terminology

What is a surgical pathology report?

This article will help you read and understand your surgical pathology report by explaining the most common sections, words, and tests used in typical reports. Your pathology report is a medical document prepared for you by a pathologist.

What is a synoptic report in a pathology report?

In most cases, a synoptic report will be included in your pathology report only after most or all of the tumour has been removed from your body. A synoptic report is usually not included when a very small tissue sample (biopsy) is sent for examination. All pathology reports include a gross description.

What are the different types of terms in anatomy?

Anatomical terms are made up of roots, prefixes, and suffixes. The root of a term often refers to an organ, tissue, or condition, whereas the prefix or suffix often describes the root.

What does CPT mean in medical terms?

Current Procedural Terminology (CPT) is a code used by all hospitals, physicians and insurance companies to identify a specific type of service or procedure. A waste product formed by the breakdown of a substance (creatine) important for converting food into energy (metabolism).

What is anatomical medical terminology?

Anatomical terminology is a form of scientific terminology used by anatomists, zoologists, and health professionals such as doctors. Anatomical terminology uses many unique terms, suffixes, and prefixes deriving from Ancient Greek and Latin.

How can we use anatomical terminology to describe body parts?

Directional termsAnteriorIn front of or frontVentralTowards the front of the bodyDorsalTowards the back of the bodyDistalAway or farthest away from the trunk or the point of origin of the body partProximalCloser or towards the trunk or the point of origin of the body part16 more rows

What are examples of anatomical terms?

Up, Down, Side-to-Side: Directional TermsAnteriorAt or near the front of the body (front view)MedialNearer to midline (side view)SuperiorToward the head/upper part of a structure (bird's-eye view, looking down)InferiorAway from the head/lower part of a structure (bottom view, looking up)7 more rows•Sep 30, 2019

What are the 4 main anatomical positions?

1.6 Planes of Reference and Directional Terms All definitions provided here assume that the human skeleton is in standard anatomical position, that is, standing erect, looking forward, with the feet close and parallel to each other, the arms at the sides, and the palms facing forward (Fig. 1.6. 1).

Why anatomical terminology is important?

The precise use of anatomical terms by health professionals allows accurate communication between colleagues, both nationally and internationally. Thus, a good knowledge of Anatomical Terminology requires an understanding of the context in which terms can be remembered 2.

Why must we use anatomical terminology?

It is important to use anatomical terminology when describing body parts to centralize communication about the body. This allows scientists and medical professionals to accurately describe anatomical locations, preventing both confusion and misunderstanding.

How do you learn anatomical terms?

SummaryLink the word to the structure by creating a mental picture.Find the meaning of the word.Break the word down and make it recognisable for yourself by using tip number 2...Create your own abbreviations, songs, poems, acronyms etc.Use flashcards, either in print commercial, online or homemade.

What are the anatomical regions of the body?

The entire human body is divided into regions, an approach called regional anatomy. Each main area (head, neck, thorax, abdomen, upper, and lower extremities) are divided into several smaller regions that aid compartmentalization.

What are the anatomical directions and body sections?

Anterior or ventral - front (example, the kneecap is located on the anterior side of the leg). Posterior or dorsal - back (example, the shoulder blades are located on the posterior side of the body). Medial - toward the midline of the body (example, the middle toe is located at the medial side of the foot).

What are the 5 anatomical positions?

The anatomical position is a standard point of reference commonly used in human anatomy and physiology when describing certain anatomical terms and positions. The five regions of the body are the head, neck, torso, upper extremities, and lower extremities.

What is anatomical evidence?

Anatomical evidences are the similarities in structures and anatomy between different organisms. The hand of a human, foreleg of ox, flipper of whale, and forelimbs of bat appear different superficially or morphologically. Also, the function of these structures is different in different animals.

What are anatomical movements?

Anatomical movements can be defined as the act or instance of moving the bodily structures or as the change of position in one or more of the joints of the body. Joint actions are described in relation to the anatomical position which is the universal starting position for describing movement.

What is gross description in pathology?

All pathology reports include a gross description. In pathology ‘gross’ refers to the way a tissue sample looks without using a microscope. The gross description is very important in the examination process. In some cases, your pathologist can make a diagnosis by looking at the tissue or reading the gross description.

What does a pathologist do?

This means that they describe what they see in the tissue sample without giving the name for a specific disease. This often includes words that are unfamiliar to people who are not medical doctors. To learn more about these words, visit our pathology dictionary.

Why is a complete and accurate clinical history important?

A complete and accurate clinical history is very important because it helps your pathologist understand why the tissue sample was sent for examination.

What does it mean when a tissue sample is negative?

“Negative” is a word pathologists use to say that something was not seen . For example, if no cancer was seen in the tissue sample, the diagnosis section may say “ negative for malignancy ”.

What is a microscopic description?

The microscopic description is a summary of what your pathologist saw when your tissue was examined under the microscope. The purpose of this section is to explain the changes seen in your tissue to other pathologists who may read your report in the future.

What is tissue specimen?

In pathology, tissue samples are called specimens. Each specimen is given a name by the doctor who sent the tissue sample to the laboratory. The specimen name should include the location and side (right or left) of the body where the tissue sample was taken.

What is the difference between excision and biopsy?

Excision – An excision is a surgical procedure that removes a small amount of tissue. The amount of tissue removed is larger than a biopsy. An excision usually removes all of the abnormal tissue with a very small amount of normal tissue. The small amount of normal tissue is called a margin.

What is a body landmark?

Body Landmarks. To precisely point out the chief complaint of a patient, the nurse or physician uses anatomical terms representing a certain body part. For example, a patient walks in the emergency room with a hacking wound on the posterior portion of the left lower leg.

What does "sural" mean in a nurse?

To clearly state the area of injury the nurse uses the term “sural” which means the posterior surface of the lower leg rather than writing “back area of the lower leg”. Knowing these terms not only give the nurse a more accurate formulation of chief complaints but it also saves time of a good deal of description.

What is the first thing you need to know about anatomy and physiology?

The first important thing in learning about anatomy and physiology is to know the anatomical position and body landmarks. To accurately describe body parts and position, initial reference point and directional terms should be used in a medical setting.

What are directional terms?

Directional Terms. To clearly explain exactly the relation of a body structure to each other, directional terms are used. For example to describe the relationship or location of the heart to the arms, we can say “the heart is located in between the arms”.

What is a bilirubin test?

Bilirubin is a substance formed when hemoglobin breaks down. A bilirubin test measures the amount of bilirubin in the blood. Blood Type ABO. A blood test that categorizes blood into one of four types: A, B, AB or O.

What is a box allergy test?

A "box" is a category test, such as of trees or mold. If a tree category allergy is detected, then an allergen-specific test would be done to determine which tree. Allergen-Specific Antigen. Allergen screen for immunoglobin E. This is an individual test for a specific allergy.

What is the lining of the uterus that grows during each menstrual cycle?

Endometrium. Mucous membrane lining of the inner surface of the uterus that grows during each menstrual cycle and is shed in menstrual blood. Endoscopic. Relating to a procedure that uses an endoscope, a long, flexible, lighted tube, to diagnose or treat a condition.

What is bilateral screening?

A group of eight tests used as a general screening tool. Bilateral. Affecting both sides of the body. For example, bilateral breast cancer is cancer occurring in both breasts at the same time. Bilirubin. Bilirubin is a substance formed when hemoglobin breaks down.

What is polymerase chain reaction?

Polymerase chain reaction, a technique used in a number of laboratory tests. Pelvic Floor. Muscles and connective tissue providing support for pelvic organs; e.g. bladder, lower intestines, uterus (in females); also aids in continence as part of the urinary and anal sphincters.

What is the valve that regulates blood flow from the heart into the aorta?

Swelling of the main blood vessel leaving the heart (aorta), usually representing an underlying weakness in the wall of the aorta at that location. Aortic Valve. The valve that regulates blood flow from the heart into the aorta.

What is the purpose of a cervical cancer test?

Relating to the chest or thorax. A test to detect and identify a bacterial, fungal or viral infection in the throat. Endocrine gland located in the neck that regulates metabolism (the chemical processes in the body) and growth; the gland produces thyroid hormone.